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Department of the Treasury Internal Revenue Service Department of Labor Pension and Welfare Benefits Administration Pension Benefit Guaranty Corporation
Annual Return/Report of Employee Benefit Plan
(With 100 or more participants)
This form is required to be filed under sections 104 and 4065 of the Employee Retirement Income Security Act of 1974 and sections 6039D, 6057(b), and 6058(a) of the Internal Revenue Code, referred to as the Code. See separate instructions
OMB No. 1210-0016
This Form Is Open to Public Inspection.
For the calendar plan year 1991 or fiscal plan year beginning
A If (1) through (4) do not apply to this year’s return/report, leave the boxes unmarked. This return/report is: (1) (2) the first return/report filed for the plan; an amended return/report; (3) (4) EP–ID
, 1991, and ending
For IRS Use Only
the final return/report filed for the plan; or a short plan year return/report (less than 12 months).
Information in 1a through 6b is used to identify your employee benefit plan. Check it for accuracy and make any necessary corrections. Also complete any incomplete items in 1a through 6b. This page must accompany your completed return/report. B IF YOU MADE ANY CHANGES TO THE PREPRINTED INFORMATION OR FILLED IN ANY INCOMPLETE INFORMATION IN 1a THROUGH 6b BELOW, CHECK HERE C If your plan year changed since the last return/report, check this box D If you filed for an extension of time to file this return/report, check this box and attach a copy of the extension 1a Name and address of plan sponsor (employer, if for a single-employer plan) 1b Employer identification number (address should include room or suite no.) 1c Sponsor’s telephone number 1d Business code (see instructions, page 19) 1e CUSIP issuer number 2a Name and address of plan administrator (if same as plan sponsor, enter ‘‘Same’’) 2b Administrator’s employer identification no.
2c Administrator’s telephone number
If you are not filing a page one with the historical plan information preprinted and the name, address and EIN of the plan sponsor or plan administrator is different than that on the last return/report filed for this plan, enter the information from the last return/report in a and/or b and complete c. Plan number a Sponsor EIN b Administrator EIN
c If a indicates a change in the sponsor’s name, address and EIN, is this a change in sponsorship only? (See instruction 3c for definition of sponsorship.) Enter “Yes” or “No.” 4 Enter the applicable plan entity code listed in the instructions for line 4 on page 8. 5a(1) Name of plan 5b Effective date of plan (mo., day, yr.) 5c Enter three-digit plan number
(2) Does this plan cover self-employed individuals? (Enter “Yes” or “No.”) All filers must complete 6a, 6b, and 6c as applicable. 6a(1) Welfare or fringe benefit plan (Enter the applicable codes from page 8 of the instructions in the boxes.)
(2) If you entered a code M, N, or O is the plan funded? (see instructions) 6b Pension benefit plan (Enter the applicable pension codes from page 8 of the instructions.) Be sure to include all required schedules and attachments. This page must accompany your completed return/report. Caution: A penalty for the late or incomplete filing of this return/report will be assessed unless reasonable cause is established.
Under penalties of perjury and other penalties set forth in the instructions, I declare that I have examined this return/report, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Signature of employer/plan sponsor Type or print name of individual signing for the employer/plan sponsor Signature of plan administrator Type or print name of individual signing for the plan administrator Date Date
For Paperwork Reduction Act Notice, see page 1 of the instructions.
Cat. No. 13500F
Form 5500 (1991)
6c Other (3) (5) (7)
plan features (if you check box (1) or (2), attach Schedule E (Form 5500)): (1) ESOP (2) Participant-directed account plan (4) Pension plan maintained outside the United States Master trust (see instructions) (6) 103-12 investment entity (see instructions) Common/collective trust (8) Pooled separate account
d Single-employer plans enter the tax year end of the employer in which this plan year ends Month e Is the employer a member of an affiliated service group? f Does this plan contain a cash or deferred arrangement described in Code section 401(k)? 7
Number of participants as of the end of the plan year (welfare plans complete only a(4), b, c, and d): a(1) a Active participants:(1) Number fully vested a(2) (2) Number partially vested a(3) (3) Number nonvested a(4) (4) Total b b Retired or separated participants receiving benefits c c Retired or separated participants entitled to future benefits d d Subtotal (add a(4), b, and c) e e Deceased participants whose beneficiaries are receiving or are entitled to receive benefits f f Total (add d and e) g g Number of participants with account balances (Defined benefit plans do not complete this line item.) h (1) Was any participant(s) separated from service with a deferred vested benefit for which a Schedule SSA (Form 5500) is required to be attached to this form? (See instructions.) (2) If “Yes,” enter the number of separated participants required to be reported Year
Yes No h(1) 8a
8a Was this plan amended in this plan year or any prior plan year? If “No,” go to item 9a Month Day b If a is “Yes,” enter the date the most recent amendment was adopted. If the date in b is in the plan year for which this return/report is filed, complete c through f
c Did any amendment during the current plan year result in the retroactive reduction of accrued benefits for any participants? d Did any amendment during the current plan year provide former employees with an additional allocation or accrual this year? e During this plan year did any amendment change the information contained in the latest summary plan descriptions or summary description of modifications available at the time of amendment? f If e is “Yes,” has a summary plan description or summary description of modifications that reflects the plan amendments referred to in e been both furnished to participants and filed with the Department of Labor? 9a Was this plan terminated during this plan year or any prior plan year? If “Yes,” enter the year b Were all plan assets either distributed to participants or beneficiaries, transferred to another plan, or brought under the control of PBGC? c Was a resolution to terminate this plan adopted during this plan year or any prior plan year? d If a or c is "Yes," have you received a favorable determination letter from IRS for the termination? e If d is "No," has a determination letter been requested from IRS? f If a or c is "Yes," have participants and beneficiaries been notified of the termination or the proposed termination? g If a is "Yes" and the plan is covered by PBGC, is the plan continuing to file a PBGC Form 1 and pay premiums until the end of the plan year in which assets are distributed or brought under the control of PBGC? h During this plan year, did any trust assets revert to the employer for which the Code section 4980 excise tax is due? i If h is “Yes,” enter the amount of tax paid with your Form 5330 $
c d e f 9a b c d e f g h
10a In this plan year, was this plan merged or consolidated into another plan(s), or were assets or liabilities transferred to another plan(s)? If “No,” go to item 11 Yes No If “Yes,” identify other plan(s) c Employer identification number(s) d Plan number(s) b Name of plan(s) Yes No 12 Enter the plan benefit arrangement code from page 9 of the instructions Yes No 13a 13a Is this a plan established or maintained pursuant to one or more collective bargaining agreements? b If a is "Yes," enter the appropriate six-digit LM number(s) of the sponsoring labor organization(s) (see instructions): (1) (2) (3) 11 14 If any benefits are provided by an insurance company, insurance service, or similar organization, enter the number of Schedules A (Form 5500), Insurance Information, that are attached. If none, enter "-0-." e Has Form 5310 or 5310-A been filed? Enter the plan funding arrangement code from page 9 of the instructions
Form 5500 (1991)
Welfare Plans Do Not Complete Items 15 Through 27. Go To Item 28. Fringe Benefit Plans see page 5 of the instructions. Yes No 15a If this is a defined benefit plan, subject to the minimum funding standards for this plan year, is Schedule 15a B (Form 5500) required to be attached? (If this is a defined contribution plan leave blank.) b If this is a defined contribution plan, i.e., money purchase or target benefit, is it subject to the minimum funding standards? (If a waiver was granted, see instructions.) (If this is a defined benefit plan leave blank.) If ‘‘Yes,’’ complete (1), (2), and (3) below: (1) Amount of employer contribution required for the plan year under Code section 412 b(1) $ b(2) $ (2) Amount of contribution paid by the employer for the plan year Enter date of last payment by employer Month Day Year (3) If (1) is greater than (2), subtract (2) from (1) and enter the funding deficiency here; otherwise, enter zero. (If you have a funding deficiency, file Form 5330.) b(3) $ 16 Has the plan been top-heavy at any time beginning with the 1984 plan year? 17 Has the annual compensation of each participant taken into account under the current plan year been limited to $222,220? 18a (1) (2) Did the plan distribute any annuity contracts this year? (See instructions.) If (1) is “Yes,” did these contracts contain a requirement that the spouse consent before any distributions under the contract are made in a form other than a qualified joint and survivor annuity? b
16 17 a(1) a(2)
b Did the plan make distributions to participants or spouses in a form other than a qualified joint and survivor annuity (a life annuity if a single person) or qualified preretirement survivor annuity (exclude deferred annuity contracts)? c Did the plan make distributions or loans to married participants and beneficiaries without the required consent of the participant’s spouse? d Upon plan amendment or termination, do the accrued benefits of every participant include the subsidized benefits that the participant may become entitled to receive subsequent to the plan amendment or termination? 19 20 21 Were distributions, if any, made in accordance with the requirements under Code sections 411(a)(11) and 417(e)? Have any contributions been made or benefits accrued in excess of the Code section 415 limits, as amended by the Tax Reform Act of 1986? Has the plan made the required distributions in 1991 under Code section 401(a)(9)? (See instructions.)
b c d 19 20 21 22a
22a Does the employer apply the separate line of business rules of Code section 414(r) when testing to see if this plan satisfies the coverage and discrimination tests of Code sections 410(b) and 401(a)(4)? b If a is “Yes,” enter the total number of separate lines of business claimed by the employer If more than one separate line of business, see instructions for additional information to attach. c Does the plan consist of more than one part that is mandatorily disaggregated under Income Tax Regulations section 1.410(b)-7(c)? If “Yes,” see instructions for additional information to attach. d In testing whether this plan satisfies the coverage and discrimination tests of Code sections 410(b) and 401(a), does the employer aggregate plans? e Does the employer restructure the plan into component plans to satisfy the coverage and discrimination tests of Code sections 410(b) and 401(a)(4)? f If you meet either of the following exceptions, check the applicable box to tell us which exception you meet and do NOT complete the rest of question 22: (1) (2) No highly compensated employee benefited under the plan at any time during the plan year; This is a collectively bargained plan that benefits only employees covered under a collective bargaining agreement, and no more than 2 percent of the employees who are covered under the collectively bargained agreement are professional employees.
g Did any leased employee perform services for the employer at any time during the plan year? h Enter the total number of employees of the employer. Employer includes entities aggregated with the employer under Code sections 414(b), (c), or (m). The number of employees includes leased employees and self-employed individuals. i Enter the total number of employees excludable because of: (1) failure to meet requirements for minimum age and years of service; (2) coverage under a collective bargaining agreement; (3) nonresident aliens who receive no earned income from U. S. sources; and (4) the 500 hours of service/last day rule j Enter the number of nonexcludable employees (subtract line i from line h) k Do 100 percent of the nonexcludable employees entered on line j benefit under the plan? Yes No If line k is "Yes," do NOT complete lines 22l through 22o. l Enter the number of nonexcludable employees (line j) who are highly compensated employees m Enter the number of nonexcludable employees (line j) who benefit under the plan n Enter the number of employees entered on line m who are highly compensated employees o This plan satisfies the coverage requirements on the basis of (check one): (1) The average benefits test The ratio percentage test—Enter value (2)
g Number h
l m n
Form 5500 (1991)
Yes No 23a Is it intended that this plan qualify under Code section 401(a)? If "Yes," complete b and c . b Enter the date of the most recent IRS determination letter c Is a determination letter request pending with IRS? 23a Month Year c 24a b
24a If this is a plan with Employee Stock Ownership (ESOP) features, was a current appraisal of the value of the stock made immediately before any contribution of stock or the purchase of the stock by the trust for the plan year covered by this return/report? (If this plan has NO ESOP features leave blank and go to item 25.) b If a is "Yes," was the appraisal made by an unrelated third party? c If dividends paid on employer securities held by the ESOP were used to make payments on ESOP loans 24c enter the amount of the dividends used to make the payments 25 Does the plan provide for permitted disparity? See Code sections 401(a)(5) and 401(l) 26 Does the employer/sponsor listed in 1a of this form maintain other qualified pension benefit plans? If “Yes,” enter the total number of plans, including this plan 27 If this plan is an adoption of a master, prototype, or regional prototype plan, indicate which type by checking the appropriate box: a Master b Prototype c Regional Prototype 28a Did any person who rendered services to the plan receive directly or indirectly $5,000 or more in compensation from the plan during the plan year (except for employees of the plan who were paid less than $1,000 in each month)? If “Yes,” complete Part I of Schedule C (Form 5500). b Did the plan have any trustees who must be listed in Part II of Schedule C (Form 5500)? c Has there been a termination in the appointment of any person listed in d below? d If c is “Yes,” check the appropriate box(es), answer e and f, and complete Part III of Schedule C (Form 5500): (1) Accountant (2) Enrolled actuary (3) Insurance carrier (4) Custodian (5) Administrator (6) Investment manager (7) Trustee e Have there been any outstanding material disputes or matters of disagreement concerning the above termination? f If an accountant or enrolled actuary has been terminated during the plan year, has the terminated accountant/actuary been provided a copy of the explanation required by Part III of Schedule C (Form 5500) with a notice advising them of their opportunity to submit comments on the explanation directly to DOL? g Enter the number of Schedules C (Form 5500) that are attached. If none, enter -029a Is this plan exempt from the requirement to engage an independent qualified public accountant? b If a is "No," attach the accountant’s opinion to this return/report and check the appropriate box. This opinion is: (1) Unqualified (2) Qualified/disclaimer per Department of Labor Regulations 29 CFR 2520.103-8 and/or 2520.103-12(d) (3) Qualified/disclaimer other (4) Adverse (5) Other (explain)
28a b c
c If a is "No," does the accountant’s report, including the financial statements and/or notes required to be attached to this return/report
disclose (1) errors or irregularities; (2) illegal acts; (3) material internal control weaknesses; (4) a loss contingency indicating that assets are impaired or a liability incurred; (5) significant real estate or other transactions in which the plan and (A) the sponsor, (B) the plan administrator, (C) the employer(s), or (D) the employee organization(s) are jointly involved; (6) that the plan has participated in any related party transactions; or (7) any unusual or infrequent events or transactions occurring subsequent to the plan year end that might significantly affect the usefulness of the financial statements in assessing the plan’s present or future ability to pay benefits?
d If c is "Yes," provide the total amount involved in such disclosure 30 If 29a is "No," complete the following questions. (You may NOT use "N/A" in response to item 30): If a, b, c, d, e, or f is checked "Yes," schedules of these items in the format set forth in the instructions are required to be attached to this return/report. During the plan year: a Did the plan have assets held for investment? b Were any loans by the plan or fixed income obligations due the plan in default as of the close of the plan year or classified during the year as uncollectible? c Were any leases to which the plan was a party in default or classified during the year as uncollectible? d Were any plan transactions or series of transactions in excess of 5% of the current value of plan assets? e Do the notes to the financial statements accompanying the accountant’s opinion disclose any nonexempt transactions with parties-in-interest? f Did the plan engage in any nonexempt transactions with parties-in-interest not reported in e ? g Did the plan hold qualifying employer securities that are not publicly traded? h Did the plan purchase or receive any nonpublicly traded securities that were not appraised in writing by an unrelated third party within 3 months prior to their receipt? i Did any person manage plan assets who had a financial interest worth more than 10% in any party providing services to the plan or receive anything of value from any party providing services to the plan? 31 Did the plan acquire individual whole life insurance contracts during the plan year?
30a b c d e f g h i 31
Form 5500 (1991)
During the plan year: a (1) Was this plan covered by a fidelity bond? If “Yes,” complete a(2) and a(3) (2) Enter amount of bond $ (3) Enter the name of the surety company b (1) Was there any loss to the plan, whether or not reimbursed, caused by fraud or dishonesty? (2) If (1) is "Yes," enter amount of loss $
Yes No 32a(1)
33a Is the plan covered under the Pension Benefit Guaranty Corporation termination insurance program? Yes No Not determined b If a is "Yes" or "Not determined," enter the employer identification number and the plan number used to identify it. Plan number Employer identification number 34 Current value of plan assets and liabilities at the beginning and end of the plan year. Combine the value of plan assets held in more than one trust. Allocate the value of the plan’s interest in a commingled trust containing the assets of more than one plan on a line- by-line basis unless the trust meets one of the specific exceptions described in the instructions. Do not enter the value of that portion of an insurance contract which guarantees, during this plan year, to pay a specific dollar benefit at a future date. Round off amounts to the nearest dollar; any other amounts are subject to rejection. Plans with no assets at the beginning and the end of the plan year, enter zero on line f.
a Total noninterest-bearing cash b Receivables: (1) Employer contributions (2) Participant contributions (3) Income (4) Other (5) Less allowance for doubtful accounts (6) Total. Add b(1) through (4) and subtract (5) c General Investments: (1) Interest-bearing cash (including money market funds) (2) Certificates of deposit (3) U.S. Government securities (4) Corporate debt instruments: (A) Preferred (B) All other (5) Corporate stocks: (A) Preferred (B) Common (6) Partnership/joint venture interests (7) Real estate: (A) Income-producing (B) Nonincome-producing (8) Loans (other than to participants) secured by mortgages: (A) Residential (B) Commercial (9) Loans to participants: (A) Mortgages (B) Other (10) Other loans (11) Value of interest in common/collective trusts (12) Value of interest in pooled separate accounts (13) Value of interest in master trusts (14) Value of interest in 103-12 investment entities (15) Value of interest in registered investment companies (16) Value of funds held in insurance company general account (unallocated contracts) (17) Other (18) Total. Add c(1) through c(17) d Employer-related investments: (1) Employer securities (2) Employer real property e Buildings and other property used in plan operation f Total assets. Add a, b(6), c(18), d(1), d(2), and e a b(1) (2) (3) (4) (5) (6) c(1) (2) (3) (4)(A) (4)(B) (5)(A) (5)(B) (6) (7)(A) (7)(B) (8)(A) (8)(B) (9)(A) (9)(B) (10) (11) (12) (13) (14) (15) (16) (17) (18) d(1) (2) e f g h i j k l
(a) Beginning of year
(b) End of Year
g h i j k Benefit claims payable Operating payables Acquisition indebtedness Other liabilities Total liabilities. Add g through j
l Line f minus line k
Form 5500 (1991)
Plan income, expenses, and changes in net assets for the plan year. Include all income and expenses of the plan, including any trust(s) or separately maintained fund(s), and any payments/receipts to/from insurance carriers. Round off amounts to the nearest dollar; any other amounts are subject to rejection.
a Contributions: (1) Received or receivable from: (A) Employers (B) Participants (C) Others (2) Noncash contributions (3) Total contributions. Add a(1)(A), (B), (C) and a(2) b Earnings on investments: (1) Interest (A) Interest-bearing cash (including money market funds) (B) Certificates of deposit (C) U.S. Government securities (D) Corporate debt instruments (E) Mortgage loans (F) Other loans (G) Other interest (H) Total interest. Add b(1)(A) through (G) (2) Dividends: (A) Preferred stock (B) Common stock (C) Total dividends. Add b(2)(A) and (B) (3) Rents (4) Net gain (loss) on sale of assets: (A) Aggregate proceeds (B) Aggregate carrying amount (see instructions) (C) Subtract (B) from (A) and enter result (5) Unrealized appreciation (depreciation) of assets (6) Net investment gain (loss) from common/collective trusts (7) Net investment gain (loss) from pooled separate accounts (8) Net investment gain (loss) from master trusts (9) Net investment gain (loss) from 103-12 investment entities (10) Net investment gain (loss) from registered investment companies c Other income d Total income. Add all amounts in column (b) and enter total a(1)(A) (B) (C) (2) (3)
b(1)(A) (B) (C) (D) (E) (F) (G) (H) b(2)(A) (B) (C) (3) (4)(A) (B) (C) (5) (6) (7) (8) (9) (10) c d
e Benefit payment and payments to provide benefits: (1) Directly to participants or beneficiaries (2) To insurance carriers for the provision of benefits (3) Other (4) Total payments. Add e(1) through (3) f Interest expense g Administrative expenses: (1)Salaries and allowances (2) Accounting fees (3) Actuarial fees (4) Contract administrator fees (5) Investment advisory and management fees (6) Legal fees (7) Valuation/appraisal fees (8) Trustees fees/expenses (including travel, seminars, meetings, etc.) (9) Other (10) Total administrative expenses. Add g(1) through (9) h Total expenses. Add e(4), f and g(10) i Net income (loss). Subtract h from d j Transfers to (from) the plan (see instructions) k Net assets at beginning of year (Item 34, line l, column (a)) l Net assets at end of year (Item 34, line l, column (b)) 36 e(1) (2) (3) (4) f g(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) h i j k l Did any employer sponsoring the plan pay any of the administrative expenses of the plan that were not reported in line 35g?
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